A 19 y.o. male comes to the ED with abdominal pain.

Two weeks earlier he had a sore throat and fever but is now recovered from that illness.

what could be wrong?

Our patient had spontaneous rupture of the spleen after mononucleosis. Mononucleosis is an Epstein-Barr virus affecting young adults.  The symptoms are usually fatigue, sore throat and fever. The spleen typically reaches maximum size in between 2 and 3.5 weeks after infection because of the production of lymphocytic  cells. In 50% of patients the splenic capsule thins and hyperplasia of the endothelial reticulum can cause vascular infarct and a subcapsular hematoma.

Despite the fact that mononucleosis is usually a self-limiting disease, if the spleen ruptures there is significant mortality.  in addition to splenic rupture, other post viral conditions have been reported after EBV.  Thrombocytopenia or hemolytic anemia may develop. Donath-Landsteiner antibodies can cause paroxysmal cold hemoglobinuria.  

subcapsular hematoma with rupture of the spleen

There has been a trend to primarily repair or embolize a ruptured spleen to preserve the spleen’s immunologic function in the case of a traumatic rupture. However, in the case of EBV infection, the spleen becomes very friable and chances of rebleeding are high.  Often splenectomy is recommended.  

Common causes of splenic enlargement included HIV, tuberculosis, endocarditis, malaria and toxo.  Leukemia, lymphoma and vasculitis are all reported to result in spontaneous rupture of the spleen.

 FUN FACTS

While  locally acquired malaria has been reported  in Florida ,Texas and Maryland in 2023, the last cases of malaria in St.Louis that were acquired locally occurred at the 1904 world fair where multiple visitors from the tropics served in the concession stands of tropical countries. 1-3 malaria cases a day were admitted to  St. Louis City hospital during the summer of 1904.

Our patient was tachycardic on arrival but never hypotensive. His hemoglobin dropped from 11.9-9.5 in four hours. He was taken to the OR and his spleen was removed. 

Won A, Ethell A. spontaneous splenic rupture resulted from infectious mononucleosis. Int J Surg Case Rep 2012;3(3):97-99.

Farley D, Zietlow S, Bannon M, Farnell M. Spontaneous rupture of the spleen due to infectious mononucleosis.  May Clin Proc. 1992;67:846-853.

Macgowan J, Mahendra P, Ager S, Marcus R. Thrombocytopenia and spontaneous rupture of the spleen associated with infectious mononucleosis. Clinical  Laboratory Haematology. 1995 https://doi.org/10’1111/j.1365-2257.1885.tb00325.x

Uzokwe C, Gwynn M, Gorst D, et al. Infectious mononucleosis complicated by hemolytic anemia due to the Donath Landsteiner antibody and severe neutropenia.1993.  Clinical and Laboratory Haematology. Vol 15(2):137-140

Yagmur Y, Kara I,  Aldemir M, et al. Spontaneous rupture of malarial spleen: two case reports and review of the literature. Crit Care 2000;4(5):309-313.

Ahbala T, Rabbani K, Louzi A, Finech B. Spontaneous splenic rupture:case report and review of literature.  Pan Afr Med J. 3030;37:36.